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Click here or scroll down to respond to this candidateDate: / / New Employee CHRC(New hire, new access, etc.)RR: DD: New Vendor / Contractor CHRC(New access)Facility Mnemonic: RAP Back Enrollment OnlyJumpseat ApplicantUPS Employee ID:Vendor ID: Vendor Name:First Name:Middle Name:Last Name: Suffix:Date of Birth:Month Day YearBirth State:Sex Circle One:Race Circle One: Asian Black White Latino Native American Other (2+) Social Security: - -Hair Color Circle One: Eye Color Circle One:Bald Sandy Black MaroonBlack White Blue HazelBlonde/Strawberry Brown Brown GrayGray/Part Gray Red/Auburn GreenHeight: Weight:Feet InchesStreet Address APT#:City:State:Country:Email: Phone:Check one:Country (if outside the U.S.)(Permanent or Temporary, if available)Male FemaleUPS Fingerprint Subject InformationPlease print in black inkPoundsCitizenship:ZIP Code:Applicant Signature: Date:CountryRevision - June 2023Docusign Envelope ID: FFC4ED1C-5404-409E-AD8F-E3590FBC79C4 Jean CarloNord22FloridaF4302 8st sw lehigh acres882073479Carlo20NordEMAIL AVAILABLEX65KYGRA29Haiti064302 8th Street Southwest200207/11/2024PHONE NUMBER AVAILABLEPierreXNord33976United States of AmericaX10Lehigh AcresX10 XEmployer InformationAddress: UPS Inc. Phone: 1 PHONE NUMBER AVAILABLE55 Glenlake Parkway NEAtlanta, GA 30328Date (Form Date must be MM/DD/YYYY Format)Region District Facility MnemonicEmployee Vendor Vendor CompanyEmployer Contact Information:Employee IDPhone NumberEmailFirst NameMiddle NameMiddle Name should remain blank only if no Middle Name was assigned at birth Last NameSuffixFirst NameMiddle NameMiddle Name should remain blank only if no Middle Name was assigned at birth Last NameSuffixFirst NameMiddle NameMiddle Name should remain blank only if no Middle Name was assigned at birth Last NameSuffixALIAS NAMESAPPLICATION FOR NEW SECURITY THREAT ASSESSMENT (STA) FULL NAMEMust Provide ALL previously used names as Aliases. Most complete name provided on the supporting documents must be listed. Employee ID / ID # of Applicant:NameExamples: Maiden names/Legal Name changes/Extended Last Names/ Spelling variations on legal documents/Names on I-9 1 of 4 Revised 06/27/2023Docusign Envelope ID: FFC4ED1C-5404-409E-AD8F-E3590FBC79C4 Jean Carlo2207/11/2024CarloPierre65PierreCarloJean Carloa04fe5da-9149-43ae-80bd-e5958d26c25aKYGRAXFirst NameMiddle NameMiddle Name should remain blank only if no Middle Name was assigned at birth Last NameSuffixDate (MM/DD/YYYY)Birth CityBirth Territory (If Applicable to your Country of Birth) GenderCurrent Mailing Address From To Current(Form Dates must be MM/DD/YYYY Format)Line 1Line 2CityStateZip CodeCountryE-Mail (if applicable)Phone NumberList current physical Address if different from above. Previous Address From To(Form Dates must be MM/DD/YYYY Format)Line 1Line 2CityStateZip CodeCountryPREVIOUS FIVE YEAR ADDRESS INFORMATIONCONTACT INFORMATIONBIRTH INFORMATIONBirth CountryBirth State (If Born within the US)2 of 4 Revised 06/27/2023Docusign Envelope ID: FFC4ED1C-5404-409E-AD8F-E3590FBC79C4 Florida33976PHONE NUMBER AVAILABLEHatiEMAIL AVAILABLELehigh AcresM10/07/2002United StatesUnited States4302 8st sw lehigh acres4302 8th Street Southwest07/10/2024Previous Address From To(Form Dates must be MM/DD/YYYY Format)Line 1Line 2CityStateZip CodeCountryPrevious Address From To(Form Dates must be MM/DD/YYYY Format)Line 1Line 2CityStateZip CodeCountryPrevious Address From To(Form Dates must be MM/DD/YYYY Format)Line 1Line 2CityStateZip CodeCountryCountry of CitizenshipPassport NumberCertificate of Birth Abroad #Naturalization DateNaturalization Certificate #Certificate of Citizenship #Alien Registration Number (USCIS #)CITIZENSHIP INFORMATION3 of 4 Revised 06/27/2023Docusign Envelope ID: FFC4ED1C-5404-409E-AD8F-E3590FBC79C4 HaitiDateEmployer Signature DateApplicant Signature(MM/DD/YYYY)(MM/DD/YYYY)Privacy Act Statement: Authority: The authority for collecting this information is 49 U.S.C. 114 and44901. Principal Purpose: This information is neededto verify your identity and to conduct a Security Threat Assessment to evaluate your suitability for completing the functions required by this position. Routine Uses: Routine usesof this information include disclosure to TSAcontractors or other agents who are providing servicesrelating to the Security Threat Assessments; to appropriate governmental agencies for lawenforcement or security purposes, or in the interests of national security; to foreign and international governmental authorities in accordance with lawand international agreement; or for this routine uses identifiedin TSAsystem ofrecords, DHS/TSA 002 Transportation Security Threat Assessment System. Disclosure: Failure to furnish your SSN may resultin delays in processing your application, but will not prevent completion of your Security Threat Assessment. Furnishingthe other information is mandatory and failure to provide it may result in you not beinggrantedauthorization to have unescorted access to air cargo. Paperwork Reduction Act Burden Statement: TSA is collecting this mandatory collection of information to qualify entities pursuant to 49 CFR 1548.15, 1548.16, 1549.111, 1544.228, and 1546.213. The public burden for this collection of information is estimated to be approximately 15 minutes. An agency may not conduct or sponsor, and persons arenot requiredto, acollection of information unless it displays a valid OMB control number. The control number assigned to this collection is OMBnumber1652-0040, which expires04/30/2024. Sendcomments regardingthis burden estimate or any other aspect of this collection of information including suggestions for reducingthis burden to TSA PRAOfficer, TSA-11,6595 Springfield Center Drive, Springfield, VA 20598-6011. ATTN: PRA 1654-0040.This information I have provided on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith, I understand that a knowing and willful false statement, or an omission of a material fact, on this application can be punished by fine or imprisonment or both (see section 1001 of Title 18 United States Code), and may be grounds for denial of authorization or in the case of parties regulated under this section, removal of authorization to operate under this chapter, if applicable. I acknowledge that if I do not successfully complete the Security Threat Assessment (STA), the Transportation Security Administration (TSA) may notify my employer. If TSA or other law enforcement agency becomes aware that I may pose an imminent threat to an operator or facility, TSA may provide limited information necessary to reduce the risk of injury or damage to the operator or facility.I have authenticated the identity and work authorization of the individual for whom this STA application is being submitted by reviewing a Photo Identification issued by a government authority and work authorization documents as required under 49 C.F.R 1540.203(b). I have verified that the individual's written application contains the Privacy Act Notice required under 49 C.F.R. 1540.203(c)(11), and I acknowledge that I am required to retain the individual's signed STA application, all documents to prove identity and work authorization, and any communications with TSA regarding the individual's application (eitherin electronic or hardcopy format) for 180 days following at the end of the individual's service as required under 49 C.F.R. 1540.203(d).4 of 4 Revised 06/27/2023Docusign Envelope ID: FFC4ED1C-5404-409E-AD8F-E3590FBC79C4 07/11/2024Sensitive Security Information (SSI) - records containing SSI are controlled under 49 CFR PARTS 15 AND 1520. employees and Authorized Representatives must not disseminate SSI material related to security procedures to anyone unless there is a Need to Know except with the written permission of the Transportation Security Administration or the Secretary of Transportation. Unauthorized release may result in civil penalty or other action. Fraud and Intentional Falsification of Records I understand that Federal Regulations 49 CFR 1540.103, that no person may make a fraudulent or intentionally false statement in any application for any security program, access media, or identification media, or any amendment. 49 1540.105 Security responsibilities of employees and other persons.(a) No person may:(1) Tamper or interfere with, compromise, modify, attempt to circumvent, or cause a person to tamper or interfere with, compromise, modify, or attempt to circumvent any security system, measure, or procedure implemented under this subchapter.(2) Enter, or be present within, a secured area, AOA, SIDA or sterile area without complying with the systems, measures, or procedures being applied to control accessto, or presence or movement in, such areas.Fingerprint ApplicationSecurity Identification Display Areas (SIDA)Last Name First Name Middle Name(Please Print Neatly)Please list any and all Aliases/Nicknames (If any) Region District Social Security Number Airport Location Code: Have you ever been convicted or found not guilty by reason of insanity of any crimes listed below in the previous ten years? 1. Forgery of certificates, false marking of aircraft, and other aircraft registration violations (49 U.S.C. 46306) Yes No 2. Interference with air navigation (49 U.S.C. 46308) Yes No 3. Improper transportation of a hazardous material (49 U.S.C. 46312) Yes No 4. Aircraft piracy (49 U.S.C. 46502) Yes No5. Interference with flight crewmembers or flight attendants (49 U.S.C. 46504) 6. Commission of certain crimes aboard an aircraft (49 U.S.C. 46506) 7. Carrying a weapon or explosive aboard an aircraft (49 U.S.C. 46505) Yes NoYes NoYes No8. Conveying false information and threats (49 U.S.C. 46507) Yes No 9. Aircraft piracy outside the special aircraft jurisdiction of the United States (49 U.S.C. 46502b) Yes No 10. Lighting violations involving transporting controlled substances (49 U.S.C. 46315) Yes No 11. Unlawful entry into an aircraft or airport area that serves air carriers or foreign air carriers contrary to established Yes No security requirements (49 U.S.C. 46314)12 Destruction of an aircraft or aircraft facility (18 U.S.C. 32) Yes No 13. Murder Yes No14. Assault with intent to murder15. EspionageYes NoYes No16. Sedition Yes No17. Kidnapping or hostage taking Yes No18. Treason Yes No19. Rape or aggravated sexual abuse20. Unlawful possession, use, sale, distribution or manufacture of an explosive or weapon Yes NoYes No21. Extortion Yes No22. Armed or felony unarmed robbery23. Distribution of, or intent to distribute, a controlled substance Yes NoYes No24. Felony Arson Yes No25. Felony involving a threat Yes No26. Felony involving:(i) Willful destruction of property(ii) Importation or manufacture of a controlled substance(iii) BurglaryYes NoYes NoYes No(iv) Theft Yes No(v) Dishonesty, fraud, or misrepresentation(vi) Possession or distribution of stolen property(vii) Aggravated assaultYes NoYes NoYes No(viii) Bribery Yes No(ix) Illegal possession of a controlled substance punishable by a maximum term of imprisonment of more than one (1) year Yes No 27. Violence at international airports (18 U.S.C. 37) Yes No 28. Conspiracy or attempt to commit any of the criminal acts listed in this paragraph Yes No The information I have provided on this application is true and correct to the best of my knowledge and belief and is provided in good faith. I understand that a knowing and willful false statement on this application is punishable by fine and imprisonment or both under Title 18 of the United States Code. I have not been convicted of any disqualifying crimes listed above in the previous ten years. I understand that if I am subsequently convicted of any of the enumerated crimes above, it is my responsibility to notify the Company of such conviction and surrender the airport-issued/airport approved identification media within 24 hours.Docusign Envelope ID: FFC4ED1C-5404-409E-AD8F-E3590FBC79C4 XXXXXXXXXXXPierreXXXXXXXXXXXXJean CarloXXX22XXXX65XXXXXXXX-XX-XXXXXID Badge Display I understand my ID badge must be displayed while present in the airports secured area. It must be visible and worn above the waist on the outer-most garment.I understand that Federal Regulations 49 CFR 1542.209 (l), impose a continuing obligation that I disclose within 24 hours if I am convicted of any disqualifying criminal offense including findings of not guilty by reason of insanity while I have unescorted access authority. I also understand that I may receive a copy of the criminal record received from the FBI if I request it in writing from the badge issuer. I understand that my access may denied at any time and upon separation from my employment this proximity card and ID badge will be returned immediately. I understand that if I should lose my ID badge, I am obligated to report the loss to the badge issuer immediately so that my badge may be removed from the system. I also understand that may be a fee, for a replacement ID badge. SCREENING NOTICE: Any employee holding a credential granting access to an airport area will be screened any time while gaining access to, working in, or leaving airport area.PRINT NAME SIGNATURE DATEI.D. VerificationLIST TWO FORMS OF IDENTIFICATION VERIFIED (ONE OF WHICH MUST BE A PHOTO ID AND ONE MUST BE ISSUED BY A GOVERNMENT AUTHORITY. ACCEPTABLE ID ARE THE SAME AS REQUIRED FOR I-9 VERIFICATION ONLY. DO NOT ABBREVIATE THE ID SOURCE. EXAMPLE: GEORGIA DRIVERS LICENSE SHOULD BE WRITTEN "GEORGIA DRIVERS LICENSE #056655125"). DATE VERIFIEDVERIFIED BY:1.2. (PHOTO I.D.)Docusign Envelope ID: FFC4ED1C-5404-409E-AD8F-E3590FBC79C4 Pierre Jean Carlo 07/11/2024Certificate Of CompletionEnvelope Id: FFC4ED1C5404409EAD8FE3590FBC79C4 Status: Completed Subject: You have documents to review and sign.Source Envelope:Document Pages: 7 Signatures: 3 Envelope Originator: Certificate Pages: 1 Initials: 0 UPS High Volume Hiring AutoNav: EnabledEnvelopeId Stamping: EnabledTime Zone: (UTC-05:00) Eastern Time (US & Canada)55 Glenlake Parkway NEAtlanta, GA 30328EMAIL AVAILABLEIP Address: 3.140.104.83Record TrackingStatus: Original7/10/2024 10:53:21 PMHolder: UPS High Volume HiringEMAIL AVAILABLELocation: DocuSignSigner Events Signature TimestampJean Carlo PierreEMAIL AVAILABLESecurity Level:.NoneID: e40958b6-4406-49d2-a8e2-a1a8e645da417/11/2024 12:15:17 AMSignature Adoption: Drawn on DeviceUsing IP Address: PHONE NUMBER AVAILABLESigned using mobileSent: 7/10/2024 10:53:22 PMViewed: 7/10/2024 10:54:03 PMSigned: 7/11/2024 12:16:26 AMElectronic Record and Signature Disclosure:Not Offered via DocuSignIn Person Signer Events Signature TimestampEditor Delivery Events Status TimestampAgent Delivery Events Status TimestampIntermediary Delivery Events Status TimestampCertified Delivery Events Status TimestampCarbon Copy Events Status TimestampWitness Events Signature TimestampNotary Events Signature TimestampEnvelope Summary Events Status TimestampsEnvelope Sent Hashed/Encrypted 7/10/2024 10:53:22 PM Certified Delivered Security Checked 7/10/2024 10:54:03 PM Signing Complete Security Checked 7/11/2024 12:16:26 AM Completed Security Checked 7/11/2024 12:16:26 AMPayment Events Status Timestamps |
